In this issue we focus on Priory Medical Group, which is pioneering a new joined up care model across the City of York. Managing Partner Martin Eades explains the initiative his organisation has put forward in the past two years.

Our new model of care started two years ago, when we were approached by the Clinical Commissioning Group (CCG) and asked how we could have an impact on reducing the number of people that were going into hospital unnecessarily. We were also asked how we could address the difficulty that some patients – particularly the elderly – have in being discharged from hospital, despite being medically fit to do so. 

Focus on the 500

We initially created a project called ‘Focus on the 500’, which looked at 500 patients and the process they followed to get into hospital then out again, and some of the difficulties that arise during the process. We worked in partnership with the local hospital and care homes on the project.

Some of the issues we focused on include why they were going into hospital in the first place, what common issues they were facing, and most importantly, whether there was a way we could support them better in the home itself, rather than in hospital.

Focusing on this catchment of 500 quickly made a difference. This was the first group of patients to have an individualised care plan, which included their wishes regarding hospital admission. We identified some common themes like infections of the chest, bladder or skin that could be easily treated in the home. However, because the project expanded so quickly, we realised that a sample of 500 wasn’t big enough to make a difference, particularly as these people were already receiving a reasonable level of support in nursing homes.

High-risk patients

We extended the project to include high-risk patients and those most at risk of hospitalisation – particularly the elderly and people with multiple chronic diseases. We were fortunate enough to have the technology in place that helped us ascertain who these people might be, and from there we developed a register to be monitored and maintained by our integrated care team. We recruited a care coordinator to work at the centre of the team, liaising with all the different providers in York that might be able to help a patient in crisis or who is at risk of going into hospital.

There is a litany of service providers involved; the list includes GPs, community nursing teams, social services and major charities like Age Concern and Diabetes UK. Just as important are the small local providers that might have been overlooked before. We had no idea what was out there until we started looking – for example there is an organisation that provides slippers for people. If patients have the correct fitting slippers, they’re less likely to fall and therefore are less likely to break a hip and end up in hospital. It’s all the little things that add up to make a big difference.

The project engaged with the public from its early stages; we attended a number of meetings with the City of York and asked people what they actually wanted and expected from their care providers. A lot of the feedback we got was that patients were feeling inundated with visitors – that a district nurse might arrive in the morning to do a routine blood test, then someone from social services would come and get them out of bed and then someone else might come later. The service these people were receiving was fragmented and there appeared to be a lack of communication between the providers. While some of the challenges around sharing records and the technology that accommodates this are still present, we’ve managed to coordinate a lot of the visitation through recruiting our own generic ‘care workers’ that are qualified to do all of the above.

New care pathways

Through the development of the team, we identified that there were clear gaps in the way care was delivered, so we needed new pathways. There were services being performed in hospitals that could have been done in a patient’s home or a nursing home, so we started looking for clinical methods that allowed us to move some treatment out of hospitals. For example, if nursing home staff were trained to administer subcutaneous fluids and IV antibiotics, it was possible to hugely decrease the amount of people who had to go into hospital for such routine procedures. The development of these pathways is still incomplete at this stage; though we are hopeful they can be delivered soon.

Fragmented care

The fragmented nature of care provision is often what lands vulnerable people in hospital in the first place. For example, a social worker might visit a patient, decide the individual doesn’t look well and call an ambulance. This is done without the healthcare record and so is based purely on a personal reaction. However, it is quite possible the regular healthcare provider is aware of this patient’s circumstances and had agreed a treatment plan that did not require hospitalisation. Once the patient is in hospital, they have to go through the whole discharge procedure before they can leave, which is why we place such priority on enabling better communication between health and social care practitioners.

Further, when people go into hospital and stay there, they decompensate. While the acute issue they were admitted for might have been treated, they’re actually less independent than when they went into hospital. As many practitioners will know, for a patient over the age of 85, ten days in hospital equates to ten years of muscle wastage. So if we can address the acute issues whilst not compromising their independence we can avoid the patient becoming more reliant on the system and the services, which bring pressures to bear that we know the public health and care system can’t sustain.

Not only is it a financial saving, but it’s also fantastic that we’ve facilitated getting someone out of hospital. Once other organisations saw the benefit of what we were trying to achieve, they jumped on board. We have a lot of people who are putting their time into this voluntarily; their organisations are seconding them for half a session or a day a week – not for any financial gain, but purely for delivering better care and setting up a model for the future that is sustainable.